ADEA CCI Liaison Ledger

Before assuming my current
responsibilities eight months ago, I served as the cultural competency
instructor at a dental school. In that role, I found that helping students
learn about culture is often fraught with resistance. Faculty members are often
frustrated as well, and who can blame them. Not only is the term “culture”
defined in various ways, but we have yet to develop an empirical way to assess
whether or not a student is culturally
competent.

Nonetheless, according to the most
recent Commission on Dental Accreditation (CODA) standards, “dental school graduates must be
competent in managing a diverse patient population and have the interpersonal
and communications skills to function successfully in a multicultural work
environment.”With each dental school
having its own unique student body, geography, faculty and patient pool, teaching
cultural competency becomes decidedly challenging, especially for those seeking
a one-size–fits-all approach.

What’s
a dental school to do?

Let’s
begin by defining culture. In social anthropology, and at its most basic level,
culture is simply “a system of symbols of a social group which are shared,
learned and passed on from generation to generation.” But more important than
what culture is, is what culture does: culture influences how people
perceive the world around them and helps guide their interactions with others.
As Harvard professor and scholar Dr. Arthur Kleinman was able to show, people
perceive and experience health and sickness through a cultural lens, for
example, one person’s chicken soup is another person’s penicillin. In other
words, culture is inseparable from the person.

We
also know that cultural competency is essential in reducing health disparities—a
priority for our profession—and that incorporating cultural competency into
patient care improves patients’ compliance and satisfaction with treatment.
This is crucial for both students and faculty to understand because it makes
the case for why cultural competency is germane to dental education and
necessary for excellence in patient care. Put another way, if we are teaching
our students to treat the whole patient, shouldn’t culture be part of their
patient evaluations?

Yes!
And I would add that in the years that I taught cultural competency to hundreds
of students, I came to realize that our typical definitions of culture tend to
be far too narrow. In my view, the definition of culture can and should be
expanded to include all the identities that people may express such as gender,
age, religion, socio-economic status and ability, to name a few. The list is
endless.

Most
of my former students, and several of my colleagues, had the misunderstanding
that cultural competency was strictly about our perceptions of race and
ethnicity. Although it is indisputable that race and ethnicity have the most
impact on perpetuating health disparities in the United States, discussions
about race in the first session of a cultural competency course can prove to be
difficult, even uncomfortable, for faculty to teach and for students to
experience. Creating a safe environment where all students can express their
opinions is essential for learning to occur.

For
this reason, I focused the first lecture of my cultural competency course on an
identity that all students share and feel comfortable discussing: the dental
student culture. This is a guaranteed way to warm up the class. Within minutes,
students shared examples of stereotypes (“faculty think we want the easy way
out and never study”), biases (“people think I couldn’t get into med school”)
and even discrimination (“I know the med school library won’t let me study
there because they don’t like dental students”). We then moved on to issues of
gender, age and ability, among others, building the students’ cultural acumen
and comfort level with biases and assumptions to the point that they felt more
secure about sharing their perceptions of race in a group setting.

Cultural
competency courses often overlook the fact that culture is as much a part of
the practitioner’s world as it is of the patient’s. To fully appreciate the
perceptions of the “other” (those different than oneself), individuals must
first understand their own cultural beliefs and assumptions. Just as the
patient views health through her own cultural lens, so does the practitioner.
In other words, cultural competency education must begin with self-exploration
of the practitioner’s assumptions about health and other cultures. We cannot
assume that the health care practitioner simply leaves his biases outside the
operatory or has no biases at all. We are all human.

As
we established earlier, culture is inextricably a part of who we are. Each
culture comes with a particular point of view inherent to our being, and often
an implicit assumption that we know better than others and that their ways of
thinking are not as good as our own or are even totally wrong. The key point,
then, that we want our students to understand? Although we all have biases and
stereotypes, the culturally competent dentist is aware of these assumptions,
can identify when they are interfering with her patient care and chooses not
act upon them. Unfortunately, many cultural competency courses fail to address
this essential element.

Recently Barbara Miller, D.D.S., Executive Director, Recruitment
and Admissions, and Lavern Holyfield, D.D.S., Director, Faculty Development,
both at Texas A&M University Baylor College of Dentistry, surveyed dental
school deans to assess their perspectives on their institutions’ cultural competency courses. The researchers asked
respondents about six domains in which cultural competency can be taught and
assessed: health disparities, community strategies, self-reflection,
cross-cultural communication, interpreters and dental culture. Respondents
rated lowest their ability to teach and assess the self-reflection and the
culture of dentistry domains. The community strategies domain, which entails
sending students outside the dental school to outreach programs where they
encounter diverse populations of patients, ranked the highest.

This
sounds good, but community service--without a self-reflective component--can
actually undermine our efforts to produce culturally competent practitioners.
If students’ assumptions about other cultures are not addressed prior to these
community-based encounters, their biases may actually be reinforced.

Here
are some of my best practices for utilizing a community outreach program as a
vehicle to improve student cultural competency. First the program should
include a pre-visit discussion of the population to be treated. Topics could
include students’ preconceptions about the population, observations that
challenge their assumptions and guidance on what students should be attuned to
while at the site. A group discussion in which students can share with each
other what they learned about other cultures and differing perceptions of
health should follow the experience. I would also ask students to write a brief
reflective essay in which they could explore their own biases that surfaced
during the outreach experience. Students should view underserved populations
not with pity or with a savior mentality but with respect for other cultures
and with the intent to incorporate oral health care education in a culturally
appropriate way.

Although
outreach sites can be fertile ground for cultural competency education, one
does not need to travel far to engage students in cultural experiences. By
expanding the definition of culture in my program, I was able to utilize the
school environment, other students and the patient pool as effective teaching
tools. Among the projects I gave my students were “explore the campus and
identify ways in which we are not culturally competent and what we can do to
improve” and “interview a classmate or patient of a different culture than your
own and compare your initial assumptions to what you learned.” Self-reflection
papers were also quite effective, especially when I allowed them to be
anonymous. I would hand them out randomly and have students read them to one
another in small groups. It’s been my experience that anonymity results in more
revealing reactions from the students and gives them the opportunity to address
their biases in a safe environment.

Cultural
competency can also be easily embedded in any interprofessional education (IPE)
activity since the goals of IPE are for students to communicate effectively and
work collaboratively in teams. Teaching cultural competency and
interprofessional collaboration together also addresses two accreditation
standards in one program. And one last tip: do not overlook the resources
provided by your parent institution. Most, if not all universities have an
office of diversity that offers training in cultural competency. I enrolled in
an eight-session cultural competency program at my university, and from that
experience I gained a wealth of knowledge that I applied to my own programming.
I also had several university experts come to the dental school campus and
speak to our students.

Just
as cultural competency is an evolutionary process composed of various
overlapping stages of personal development, so too should be our approach to
teaching culture. We as educators can evolve by broadening our definition of
culture and engaging our students in all the identities they bring to the
profession by linking culture classes to health disparities and patient
satisfaction, by capitalizing on outreach opportunities and other experiential
programs and by having our students self-reflect. By utilizing all the
resources our schools and universities offer, cultural competency education can
be an effective and transformative experience for our students and our
profession.